Provider Demographics
NPI:1740551019
Name:GUILLERMO F PORRO DMD PA
Entity type:Organization
Organization Name:GUILLERMO F PORRO DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:I
Authorized Official - Last Name:PROSPERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-889-8599
Mailing Address - Street 1:7059 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2290
Mailing Address - Country:US
Mailing Address - Phone:813-889-8599
Mailing Address - Fax:813-249-1301
Practice Address - Street 1:7059 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2290
Practice Address - Country:US
Practice Address - Phone:813-889-8599
Practice Address - Fax:813-249-1301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10372261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074901001Medicaid